HomeMy WebLinkAboutDEER PARK #1 BLK 1 LT 5Deer Park #1
Block 1
Lot 5
#051-042-56
municipamy OT Hncnorage
On -Site Water and Wastewater Section • (907) 343-7904 Page of
ON-SITE WASTEWATER INSPECTION REPORT
Permit Number: OSP211230 PID Number: 051-042-56
Dwelling: ® Single Family (SF) ❑ with ADU ❑ Duplex (D) ❑ Two Single Family Project: ❑ New Upgrade
Name
A iJRPTION FIELD
Vickie Padello
D Trench
IED]❑ Wide Trench ❑ Bed ❑ Mound
Site Address
22494 Deer Park Dr.
Other
Phone
Number of Bedrooms
Soil Rating
Total depth from original grade
3
ISF
Ft.
LEGAL DESCRIPTION
Depth to pipe invert from original e Gravel depth beneath pipe
Ft.
Subdivision Block Lot
Deer Park #1 1 5
Fill added above original grade Gr length
FL FL
Township Range Section
Gravel width
Ft.
Beds: Number of Lines
Dista between lines
Ft.
SEPARATION DISTANCES
To
Septic
Absorption
Holding
Sewer
Total absorption area
Number of trenches
Dist, between tr es
From
Tank
Field
Lift Station
Tank
Line
Ftz
Well
100'+
TANK ❑ Septic EJS.T.E.P. E] Holding [I Other
Manufacturer
Greer
Capacity
10()0 Gal.
Surface Water
100'+
Material
Plastic
Number of compartments
2
Lot Line
51+
NA
Foundation
5.5'x
j
ATION
Manufacturer Capacity
Gal.
j
Remarks- field verified 5.5'separation from deck
foundation post, 10'+ from building foundation.
Alarm location Electric d by
Field verified 5'+ separation from tank to existing leach field.
PIPE MATERIAL House to tank Tank to
D3034 drainfield D3034
Installer
Pionier Peak Ind.
Drainfield CO/MT D3034
Inspector Areterra Consulting
BENCH MARK (Assumed elevation) 100 ft
Inspection
dates: 7/19/21 2„d 7/19/21
Location and description
TO 7/20/21 a'" 7/21/21
Building foundaion
ON-SITE WATER AND WASTEWATER SECTION APPROVAL
Engineer's Stamp
Conditional Approval: DateNot
Aw
Id ��
01
�+ KENNETH FFUS t++ffi
Septic System��
7�t �
Approved Date � 1 1 a02 i
t�®lF� � �V
Note: this does include
...• .�
approval not well permit requirements.
INN
(Rev 05/02/18)
AS—BUILT SYSTEM DETAILS/SITE PLAN Permit ❑SP211230
DEER PARK #1 BLOCK 1 LOT 5 PID# 051-042-56
NEW 1000
GAL TANK
Lot 4
SNL I.HR
� / 0
0
El
� / Y
CV
v
N /
m A -C=36,8'
B -C=13.4
98.3
A -D=37.0'
W
0. B -D=15,4'
A-E=35,9'B-E=18.8'
co3f nnA-F=31.9'B-F=19,1'oa
;77
A -G=30 3'
�' 0o GAL
B -G=19,3'
a EPTICA-H=28.1'
ANK
SCALEt NTS
■}
0
EXISTING
TRENCH
GRAVEL
PREPARED FOR:
VICKIE PADELL❑
22494 DEER PARK DRIVE
CHUGIAK, AK, 99567
FIELD BOOKS
BOUNDARYBOUNDARY: N/A
STMNG N/A
ASBUILT: LANG
DWG. FILE:
AGAD FIm` FILE
CDNPUTO:
DRAWN: KSD
MEMO: KMD
DATE, 7/30
MD' NW15E
'IDB N' 21049
Lot 21
SCALE, 1' = 30' \
SCALE, NTS
0 10 25 50 100
SCALE 1"=40'
Lot 4
WOODEN
Lot 6
Lot 5
40,747 s.f.
Lot 21
FENCE
10' UTILITY i
EASEMENT -
5' T&E
— EASEMENT//
o� \ N 84'11'25"W 120.64' —�/—
N
'4DEER PARK DRIVE
PLAN – _ AS BUILT
Lang & Associates, inc.
Professional Land Surveyors
Daryl Avenue, Anchorage, Alaska
522-6476 Phone
522-4625 Fax c
I hereby certify that 1 have surveyed the following described property:
LOT 5, BLOCK 1, DEER PARK – ADDITION No. 1 (PLAT No. 82-133)
Anchorage Recording District, Alaska, and that the improvements situated thereon are
within the property lines and do not encroach onto the property adjacent thereto, that
no improvements on the property lying adjacent thereto encroach on the surveyed
premises and that there are no roadways, transmission lines or other visible
easements on said property except as indicated hereon.
1VDated this the __2cDay of ---______- _=�T. at Anchorage, Alaska
99515-3049
OF.A
49TH
............. -..,.A ..........
KENNEYH LrANG U o
hp L-5202.NoyopG
����FESSIONA� 00
0
It is the responsibility of the owner to determine the existence of any easements,
covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963
PIPES
Z
O
00
/ 25 PROW CANT
y
MANHOLE /
_'
STORAGE `' GRNIT
O
U
lI
4p 3 N
W
cam^
SIG,` I p -
ri
r
U
?"SOGN.C'Sol 19.2'
i
Ut
J
Z
I
w.
2).
SHED P
\
own
/
I
I
FIRE
PIT p
Ix
WOODE\
FENCE
vo
\
GN
tx
/
Lot 21
\
CHAIN-LINK FENCE
N
h
P
WELL—,-
I
I
10' UTILITY i
EASEMENT -
5' T&E
— EASEMENT//
o� \ N 84'11'25"W 120.64' —�/—
N
'4DEER PARK DRIVE
PLAN – _ AS BUILT
Lang & Associates, inc.
Professional Land Surveyors
Daryl Avenue, Anchorage, Alaska
522-6476 Phone
522-4625 Fax c
I hereby certify that 1 have surveyed the following described property:
LOT 5, BLOCK 1, DEER PARK – ADDITION No. 1 (PLAT No. 82-133)
Anchorage Recording District, Alaska, and that the improvements situated thereon are
within the property lines and do not encroach onto the property adjacent thereto, that
no improvements on the property lying adjacent thereto encroach on the surveyed
premises and that there are no roadways, transmission lines or other visible
easements on said property except as indicated hereon.
1VDated this the __2cDay of ---______- _=�T. at Anchorage, Alaska
99515-3049
OF.A
49TH
............. -..,.A ..........
KENNEYH LrANG U o
hp L-5202.NoyopG
����FESSIONA� 00
0
It is the responsibility of the owner to determine the existence of any easements,
covenants, or restrictions which do not appear on the recorded subdivision plat. AECC963
M UNI IPAL17Y OF ANCHORAGE
On -Sita Dater & Wastewater Program
130 EkM 198850 4790 6mom Roo
Anchorage. Maska 995fME50 Phone: (07) 343-7904 Fax JW) 3+1 7997
ht0jf ww.rrwni,ar3hertglke
On -Site Wastewater Disposal ystem Permit
Permit Nurn lor; GS P21 1230
Work Type, $eplicTsnk Llpgradi?
Tom 04d� Nurnbcr; 0$1042560W
Site Legal Add Fuss; DE ER PARK # 1 ELK 1 LT 5 G=1558
5 ite Mai I in g Address,. 22494 D EER PARK DR, C hu gia k
Own er: PADELLO VICINE
Desi g n Engineer: FIRST DATE R CON SU LTI NG
This perms is for the construction of:
Effective Date;
Expiration Date;
Lot Size in Sq Ft:
Total Bedrooms;
&28l2021
612812022
40747
❑ Disposal Field Q Septic Tank ❑ Holding Tank. ❑ Privy 0 PrivaZe Well ❑ Arazer Storage
All constroctiori shiall be in ACCurdancewith:
1. The attache -d approvGd deslgn.
2. All requ ireme n is sPeciffed in Ari c;hofage Muri iolpal Code Chaptiam 15.55 and 15.65 and the, State of Alaska
Wastewater Di sposai regulations (1 SAAC72 � and Drtnking Waller Rag ulalioris �18AA080)
;a. The wmilcw o1-cr 4oLjc roquirco iil5pr iiurij duririg Me imAwlfation_ The engineer shall no ft she Development
Sarvlcas DeparbmGrt per AMC 15.65_ Provide notificatlon tq Ca11ino (9 07) 343-7904 X24{7).
4, From 4ctDber 15 to April 15, a subslurface soil absorption system under construction during freezing weather
Shall be either_
a. Opened and Closed ori Me sarne day, or
b. Covered, sealed, and heated to prevent freezing
Special Provisions:
Min imam 5 It sQp� rali o 0 bel.w n r ew tan k and exi sting cl ra infield shall be confirmed at time of inst3I latio n-
M
ir imum 5 ft Separation between new tank and deck supporks shall be provided or deok S�1pp4rtFr ShaCl be
driven :�Q that the terik is outside the soil bearing prism of the suppprls.
R 000lved
Issued Ey.
&28=1
Date:
Date: o
s
MUNICIPALITY OF
Development Services Departmentu
On -Site Water & Wastewater Section -
Parcel I.D. 051-042-56
ON-SITE SEPTIC/VVELL PERMIT APPLICATION
Property owner(s) VICKIE PADELLO Day phone
Mailinq address 22494 DEER PARK DRIVE, CHUGIAK, AK 99567
Site address 22494 DEER PARK DRIVE, CHUGIAK, AK 99567
Legal description (Sub'd., Block & Lot) DEER PARK #1 131, L5
Legal description (Township, Range & Section)
Lot Size 40747 Sq. Ft. Number of Bedrooms 3
APPLICATION IS FOR:
(® all that apply)
Absorption Field
❑
Septic Tank
0
Holding Tank
❑
Privy
❑
Private Well
❑
Water Storage
❑
Phone: 907-343-7904
Fax: 907-343-7997
APPLICATION IS AN: TYPE OF DWELLING:
Initial ❑ Single Family (SF) 0
(
Upgrade 7Xw/wo ADU)
Renewal ElDuplex (D) ❑
Multiple Dwellings ❑
(SF and/or D)
THIS APPLICATION INCLUDES A WAIVER REQUEST FOR:
Distance:
I certify that the above information is correct. I further certify that this is in accordance with
applicable Municipal Codes.
ature of property owner or authorized agent)
Permit/Rush Fees: is a a O
Date of Payment: A I
Receipt Number: 3 IZy2
Permit No. 6 SQ
Waiver Fees:
Date of Payment:
Receipt Number:
Waiver No.
GADevelopment Services\Building Safety\On Site Water and Wastewater\Forms\Client Forms\Permit Application.doc
13030 Sues Way, Anchorage, AK 99516
907-350-9566 / firstwaterAK@gmail.com
June 21,2021
Municipalities of Anchorage
On-Site Water & Wastewater Program
4700 Elmore Road
Anchorage, AK 99507
RE: SEPTIC TANK UPGRADE PERMIT
LEGAL: DEER PARK #1 BLOCK 1, LOT 5
The owner has requested that we obtain a septic permit to upgrade the existing aged steel septic
tank on the above referenced lot. We propose to install a 1000-gallon HDPE tank per the
attached design to serve the existing 3-bedroom residence. The lot and area are served by private
wells and public water. The design will not impact any of the neighboring properties. Please
contact us if you have any questions.
Sincerely,
Curtis Huffman, P.E.
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211230, Rebecca Carroll, 06/28/21
Municipality of Anchorage
On-site Water and Wastewater
REVIEWED FOR CODE COMPLIANCE
OSP211230, Rebecca Carroll, 06/28/21
MUNICIPALITY OF ANCHORAGE `
DEPARTMENT OF HEALTH & ENVIRONMENTAL PROTECTION
ENVIRONMENTAL ENGINEERING DIVISION
825 L Street • Anchorage, Alaska 99501 Telephone 2644720
ON-SITE SEWAGE DISPOSAL SYSTEM AND/OR WELL INSPECTION REPORT
NAME
PHONE NEW
}
/
694-1 [3UPGRADE
MAILING ADDRESS
6enerig
LEGAL DESCRIPTION
Ga a tP LT !l/
LOCATION
Po
NO. OF BEDROOMS ^
m o
3
U
Well /(i0 ')'
DISTANCE TO:
Absorption area
Dwelling 3
PERMIT NO*62 2
—Y
H 2
Manufacturer
Material
No. of compartments
h�
reer
see/
2
4q. capacity in gallons
IF HOMEMADE:
Inside length_
Width _
Liquid depth
d y
DISTANCE TO:
Well
Dwelling
PERMIT NO.
JV2
==H
Manufacturer
Material
Liquid capacity in gallons
O
W=
DISTANCE TO:
Well
/00 r
Foundation i
O
Nearest lot line �f i
23
PERMIT NO.
'820234
W
No. of lines
Length of each line i
Total length of lines ,
Trench w.dth
Distance between lines
/
nchat
F-
Top of the to finish grade ,/ /,
4
Material beneath the
Total effective abso.ption area
O
96 inches
6�
Length
Width
Depth
PERMIT NO.
W
i H
W�
Type of crib
Crib diameter
Crib depth
Total effective absorption area
w
DISTANCE TO:
Well
Building foundation
Nearest lot line
J
Class
Depth
Driller
Distance to lot line
PERMIT NO.
J
DISTANCE T0:
Building foundation
Sewer line
Septic tank
Absorption areafs)
OTHER
PIPE MATERIALS
SOIL TEST RATIN
226 f%.
INSTALLER
l h h ln P P rs
REMARKS
Coldracter )eu C 42 i l
!zod 4' above the pfrfonqp
e.S Uts 3'
E_a
19
ll
V
s,
sP
/
War rallIle.
7 �/
z
%o
ir'-A
®W
lI
ILL
5'0 . -i lI go f lewc-A fi
APPROVED DATE LEGAL
Deer Park Esta ter LatS block
72-013 (Rev. 3/78) '
ty�_�tJ I C I F iL I T•r OF Ffr-4r--" ?r it E NO
DEPARTMENT i HEALTH AND ENVIRONMENTAL h OTECTION
835 'L' STREET, ANCHORAGE, AK. 99501
2r,4-4720 4�
1JEL_l_ Ht}IG• CIr-J—� I TE " EI• E:F: F•ERr•1 I T
PERMIT NO. ( 830224 )
APPLICANT STEVEN R E. DIANE M PETE GENERAL DELIVERY
6.44-2452
LOCATION DEER PARI( ESTATES ##1
LEGAL L5 B1 LOT
SIZE 40747 SQUARE FEET
TYPE OF SOIL ABSORPTION SYSTEM IS: DR:AINFIELE>
2ZG So+�
MFIXIMUM NUMBER OF BEDROOMS = Z SOIL RATING, (SQ
FT;BR)= "�_
THE REQUIRED SIZE OF THE SOIL ABSORPTION SYSTEM IS:
G•EF•TH== LEr•JGTH= 1GocD
C•EF•TH— J°!�
THE LENGTH DIMENSION IS THE LENGTH (IN FEET) OF THE
TRENCH OR: DRAINFIELD.
THE DEPTH OF A TRENCH OR PIT IS THE DISTANCE BETWEEN
THE SURFACE OF THE
GROUND AND THE BOTTOM OF THE EXCAVATION (IN FEET).
THE=TF~�t.br'i••i—F•f I-E°-l-f-��Y =. �—.�r�rr-7=-'E-E-�f�
THE GRAVEL DEPTH IS THE MINIMUM DEPTH OF GRAVEL BETI•IEEN
THE OUTFALL PIPE
AND THE BOTTOM OF THE EXCAVATION (IN FEET).
F'EC!t_l I REG• �EF•T I r TRr-JK � I cE=
1R=IC."iC+ lZ�HLLror-J1
PERMIT APPLICANT HAS THE R:ESPOtSIBILITY TO INFORM THIS DEPARTMENT DURING THE
INSTALLATION! INSPECTIONS OF ANY WELLS ADJACENT TO THIS PROPERTY AND THE
NUMBER OF RESIDENCES THAT THE WELL WILL SERVE.
--- T140 •` � ? I r41—F•EIZ:-IF I ED, r•J� F1F:E F:EIDt_1 I RELY ---
EACKFILLING OF ANY SYSTEM WITHOUT FINAL INSPECTION AND APPROVAL BY THIS
DEPARTMENT HILL BE SUBJECT TO PROSECUTION.
MINIMUM} DISTANCE BETWEEN A WELL AND ANY ON-SITE SE14AGE DISPOSAL SYSTEM IS
100 FEET FOR A PRIVATE WELL OR 150 TO 200 FEET FROM A PUBLIC WELL DEPENDING
UPON THE TYPE OF PUBLIC WELL.
MINIMUM DISTANCE FROM A PRIVATE l•JELL TO A PRIVATE SEWER LINE IS 25 FEET AND
TO A COMMUNITY SEWER LINE IS 75 FEET.
WELL LOGS ARE REQUIRED AND MUST BE RETURNED TO THE DEPARTMENT WITHIN 30 DAYS
OF THE WELL COMPLETION.
OTHER REQUIREMENTS MAY APPLY. SPECIFICATIONS AND C_.ON_TRUCTION DIAGRAMS ARE
R'•/AILABLE TO INSURE PROPER INSTALLATION.
F•ERr•1 I T E}tiF IRE=. C•ECEt'tE3ER X11 :I_
I CERTIFY THAT
1: I AM FAMILIAR. WITH THE REQUIREMENTS FOR ON-SITE SEWERS AND WELLS AS SET
FORTH BY THE MUNICIPALITY OF ANCHORAGE
I WILL INSTALL THE SYSTEM IN ACCORDANCE WITH THE CODES.
_. I UNDERSTAND THAT THE ON-SITE SEWER SYSTEM MAY REQUIRE ENLARGEMENT IF THE
RESIDENCE IS REMODELED TO INCLUDE MORE THAN 3 BEDROOMS.
1 2_C!L.�-----------------� It ct��j l7
SIGNED:__-- _ --
APPLICANT STEVEN R A. DIA14E M PETERSON �(ti (
l�6 ,��
ISSUED 84�Z ��//- - =--------DATE/L�d --- fZ) h•� V4. 0
=r r
❑ SOILS LOG
MUNICIPALITY OF ANCHORAGE
DEPARTMENT OF HEALTH AND ENVIRONMENTAL PROTECTION PERCOLATION
et, Anchorage. TEST
825 L. Street,
eq•, Aleske 99501 264J720
SOILS LOGr— PERCOLATION TEST
PERFORMED FOR: S1l CAVA 1-.rWlr L�/1/(r_rNi£/e S DATE PERFORMED: inni
LEGAL DESCRIPTION: LOT/ LS 6141 flips = Qf4iC PLtRK sSrAr£S
TF E ) ff�`(l S"j SLOPE SITE PLAN
t J I 1\-L 17
2
3 •'%O
5 ,d
6-
7-
8-
9-
7 6 9 ; 1r
to f�
..l
tt %r a
�D
14-
15-
17-
4 15 n p
18 xe
19 ♦�
20
COMME
PERFORMED BY:
72-008 (6/79)
9An►D d
Kassa A.
NO. 14
Fa Fa
*1
ENCOUNTERED? L
IF YES, AT WHAT ENNEEMENOMM
' ■��M■NN■E■
Reading
Date
Gross
Time
Net
Time
Depth to
Water
Net
Drop
z
30,,,7,
&
I%L
&:0
ID r,.:�
Iz yq
9 �
!I
i O r
10 M4,
/2
PERCOLATION RATE 7-41 (minutes/inch)
TEST RUN BETWEEN (9 FT AND Z FT
CERTIFIED
\
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.s
,s
oil
_I �_ I 1
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OL FrV- 4� BUBO/U/S/0
roe--`------ —
SHEET NO — -_— OF
CALCULATED By — DATE
CHECKED BY DATE
SCALE
(D Tic
7Y/Z
Mtcs)
. -... ® ( aro
1_..__:.. .. ..
® 7PM
jw
ALASKA ENVIRONMPxTAL
q! '
CONTROL SERVICE:., NC.
1220 West 25th Avenue
F , 5
ANCHORAGE, ALASKA 99503
Phone 276.1361
•WIN _I. i .
Mr w
.s
,s
oil
_I �_ I 1
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OL FrV- 4� BUBO/U/S/0
roe--`------ —
SHEET NO — -_— OF
CALCULATED By — DATE
CHECKED BY DATE
SCALE
(D Tic
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Mtcs)
. -... ® ( aro
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® 7PM
r 2112g79
ALASKA EIIUB011mEi U C011TROL SMICCS, Inc.
Enginecrinq & Enuironmental Studies
January 22, 1982
Triad Engineering, Planning & Surveying
6937.01d Seward Highway
Anchorage, Alaska
99502
Attn: Dave Grenier
Dear Dave:
Attached are the soils logs for 3 new test holes in Deer Park
Subdivision. I did not detect water in any of the test holes.
The water level in TP3 was LLjeet below the ground level. On
September 22, 1981 it was at —7 ft.
When JMLamb & Associates did their study in September, 1981
water was present in this area at a higher level. We did not
observe any water in the 3 test pits. One can assume that
there are asonal fluctuations that are a function of the
amount of rain a mer apparently percolates through the
gravels quite rapidly and then more slowly through the
underlying silty gravels. I believe shallow systems!etould be
better than deeper systems in the areas w ere >Te water table
fluctuates drastically.
If you have any questiors please let me know.
Sincerely,
Leroy Rein Jr.,lD, FE
Presid nt
@2o West 25th Autnue • Anchoragt. Alaska 99503 0 (901) 216-1361
7-
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Municipality of Anchorage
On -Site Water and Wastewater Program
(907) 343-7904 5 1 1 E T
CERTIFICATE OF ON-SITE SYSTEMS APPROVAL
Parcel I.D. 051-042-56
1. GENERAL INFORMATION
Complete legal description _Deer Park #1 Block 1 Lot 5
Expiration Date: Nv_' 1.1
Location (site address) 22494 Deer Park Dr. Chugiak AK__9.9567
Current Property owner(s) Vickie Padello_ Day phone
Mailing address 22494 Deer Park Dr._Chugiak, AK 99567
Real Estate Agent
2. TYPE OF DWELLING:
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS:
4. TYPE OF WATER SUPPLY:
Individual Well
z
Individual Water Storage
❑
Community Class Well
❑
Public Water System
❑
Waiver/Variance request for:
3
Day phone
TYPE OF WASTEWATER DISPOSAL:
Individual
Holding Tank
❑
Community
❑
Public Sewer
❑
Received by: _ _ Date:
COSA to be released to the engineer, unless otherwise requested by the engineer.
COSA Fee $--6,50
Date of Payment zd.2
Receipt Number 055926
COSA # 05C, 2-1 I g 5 8
Waiver Fee $
Date of Payment _. _ __,
Receipt Number
Waiver #
Distance:
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are) in compliance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm ARCTERRA_CONSULTING, INC. . _ Phone _ 696-6111
Address 20441 PTARMIGAN BLVD., EAGLE RIVER, AK 99577__,____
Engineer's Printed Name KE__NNETH M.. DUFFUS
Date z�_
Engineer's Comments: This investigation was completed in compliance with ADEC and MOA regulations. The assessment of the condition
of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change due to subsurface
conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate
during the year and the water usage of the family being served by the system. The operational life of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore,
ArcTerra can not give any estimate of how long a
system will function satisfactory for current or future
occupants or can ArcTerra guarantee that no unseen .g ,,. OF
encroachments, deficiencies or discrepancies exist. ,� ��a� �• �; >
6. DSD SIGNATURE
✓ System #1 Approved for
System #2 Approved for
Disapproved.
Conditional approval for
3 bedrooms.
bedrooms.
bedrooms, with the following stipulations:
P
P PM �l
4 -- -- ----
By _.. .. .__ _ _ Original Certificate Date:_
The Municipality of Anchorage Development Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by an independent professional civil engineer registered in the State of Alaska. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory ____________ Other
COSA blue sheet -10-1 0-12 doc
Legal Description:
COSA Checklist
Deer Park 91 Block 1 Lot 5
If more than 1 septic system on lot: COSA Checklist #
A. WELL DATA
FO -1 Well log is filed with Onsite (or attached)
Date drilled 6/16/82
Total depth 165 ft
Cased to 165 ft
® Sanitary seal is functioning correctly
® Wires are properly protected
Casing height (above ground) 24+ in.
Date of flow test for COSA 6/14/21
Static water level at beginning of test 109 ft.
Parcel ID: 051-042-56
of Structure served by this system
Well production at time of test 2.7 _g pm
Water storage tank volume gallons
Well disinfected for coliform test? ❑ Yes E No
FW Coliform bacteria is Negative
Nitrate 0.676 mg/L ❑ Nitrate less than MRL (ND)
Arsenic ug/L FR— Arsenic less than MRL (ND)
Collected by _
Date of Sample
Comments x Measurements and well production test done by First Water on 6/14/21.
B. TANK DATA
Age of tank(s) New years
Tank type/material Se. gtic/Plastic
Measured operating fluid level in septic tank New
IN Standpipes/foundation cleanout per record drawing
Date of pumping New tank installed 7/20/21
D. ABSORPTION FIELD DATA
Which system tested (date installed) 1014/82
MI ALL standpipes present per record drawing
Total measured depth from grade 11.3 ft (max)
Measured depth to pipe invert from grade 3.8 ft (min)
❑ N/A — pressurized field
❑ Monitor tubes go to bottom of effective. If not, state
depth into effective 7.5
FT STATION
First Water
6/14/21
❑ Requ aintenance completed
Age of lift station years
Lift station material
Comments:
Adequacy test date 6/14/21
Results Q✓ Pass For 3 bedrooms
Fluid depth prior to test 55 in
Water added 450 gal
New depth 64 in
Elapsed time 1260 min
Q Code -required soil cover over field Final fluid depth 55 in
❑ System presoaked Absorption rate 450+ gpd
(Required if vacant for greater than 30 days prior to Any rejuvenation treatment (past 12 months)
date of test)
Gallons introduced gallons If yes, enter date
Comments/Deficiencies:" Measurements and adequacy test done I)v Firsi Water on 6/14/21.
COSA Checklist yellow sheet
E. SEPARATION DISTANCES
From Private Well on Lot to: (Please enter distances if less than required or if community well)
Septic Tank/Lift Station on Lot > 100'
® Yes if No ft
Wells on Adjacent Lots:
Community Sewer Manhole/Cleanout > 100'
0 Yes
if No
ft
[0 Yes
if No ft
Neighboring Tank > 100' 0 Yes
if No
ft
Private Sewer/Septic Line > 25' Yes
if No ft
Absorption Field on Lot > 100' ® Yes
if No
ft
Holding Tank > 100' ® Yes
if No ft
Neighboring Absorption Fields > 100'
Surface Water > 100'
® Yes
Animal Containment > 50' ® Yes
if No ft
® Yes
if No
ft
Manure/Animal Excreta Storage > 100'
Community Sewer Main > 75' ® Yes
if No
ft
0 Yes
if No ft
From Septic/Holding Tank on Lot to: (Please enter distances if less than required)
Building Foundations > 10' 0 Yes if No ft Surface Water > 100' ® Yes if No ft
Property Line > 5'
® Yes if No ft
Wells on Adjacent Lots:
Absorption Field > 5'
® Yes if No ft
Private Wells > 100' 0 Yes if No ft
Water Main > 10'
® Yes if No ft
Community Wells > 200' 0 Yes if No ft
Water Service Line > 10'
® Yes if No ft
If septic tank is under driveway comment below
From Absorption Field on Lot to: (Please enter distances if less than required)
Building Foundation > 10'
Yes
if No
ft
If absorption field is under driveway comment below
Property Line > 10'
® Yes
if No
ft
Wells on Adjacent Lots:
Water Main > 10'
® Yes
if No
ft
Private Wells > 100' 0 Yes if No
Water Service Line > 10'
® Yes
if No
ft
Community Wells > 200' ® Yes if No
Surface Water > 100'
® Yes
if No
ft
F. ENGINEER'S COMMENTS
G. ENGINEER'S CERTIFICATION ♦+~+� OF
1 certify that / have determined through field inspections and review
of Municipal records that the above systems are in conformance with
MOA COSA guidelines in effect on this date.
L_sKENNETH M FUsl4
�' d,
ot F0
COSA Checklist yellow sheet
Iii
ft
• Municipality of Anchora Nov 16 2015 )1- °`
On-Site Water and Wastewater Program6;
(907 343-7904 t<< h� s. E,r
CERTIFICATE O TEMS APP
Parcel I.D. 051-042-56 r° •� `' - Expiration Date:
�Y,
1. GENERAL INFORMATION
Complete legal description DEER PARK#1 1, LOT 5
Location (site address) 22494 DEER PARK DRIVE, CHUGIAK, AK 99567
Current Property owner(s) JAMES & JENNA'CHRISTIAN Day phone
Mailing address 22494 DEER PARK DRIVE, CHUGIAK, AK 99567
Real Estate Agent Day phone
2. TYPE OF DWELLING:;
® Single Family (w/wo ADU)
❑ Duplex
❑ Multiple Dwellings (Single Family and/or Duplex)
3. NUMBER OF BEDROOMS: 3
4. 'TYPE OF WATER SUPPLY: TYPE OF WASTEWATER DISPOSAL:'
Individual Well ® Individual 0
Individual Water Storage ❑ Holding Tank El
Community Class Well ❑ Community El
Public Water System ❑ Public Sewer ❑
WaiverNariance request for: ay�Ai `�-c� �'dt/wt r�t� tiil: Distance:
Received by: Date: ✓Z S-
COSA to be releagc engineer, unless otherwise requested by the engineer.
COSA Fee $ 5d(o _ Waiver Fee (F"If CLMIE4
Date of Payment (j 1611! _ Date of Payment
Receipt Number Receipt Number
COSA# YJcts Waiver # osv/�;-11�5-
5. STATEMENT:OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Certificate of On -Site Systems Approval Guidelines for this application,
shows that the on-site water supply and/or wastewater disposal system is (are) safe, functional and adequate
for the number of bedrooms and type of structure indicated' herein. I further verify that based on the information
obtained from the Municipality of Anchorage files and'from- my investigation and inspection, the on-site water
supply and/or wastewater disposal system is(are)'in'compiiance with all applicable Municipal and State codes,
ordinances, and regulations in effect at the time of installation.
Name of Firm-ARCTERRA CONSULTING, INC. Phone 868-3791
Address _20441 PTARMIGAN BLVD., EAGLE RIVER AK 99577
Engineer's Printed Name KENNETH M. DUFFUS Date 10-15-2015
Engineer's Comments: This investigation was completed incompliance with ADEC and MOA regulations. The assessment of the condition
of the well and septic applies only to the conditions as of the day tested. The flow and absorption rates may change. due to subsurface
conditions that may not be observed from the surface, changes inland use, local soil characteristics, groundwater levels that may fluctuate -
during the year and the water usage of the family being served by the system. The operationallife. of all well and septic systems are
subject to these various and dynamic characteristics and are outside the control of the
evaluator of the well and septic system. Therefore, -
ArcTerra can not give any estimate of how long a
system will function satisfactory. for current or future
occupants or can AreTerra guarantee that no unseen �.GG OFA
encroachments, deficiencies or discrepancies exist. w
_l
� 4 Tr -i
6. DSD NATURE
System #1 Approved for bedrooms. KENNETH tNs eusl�
System #2 Approved for bedrooms.
Disapproved.
Conditional approval for bedrooms, with the following stipulajigtlNttrrr
�Rp,GE Np7sr,
zl-t-o �
o��,�
By: Original Certificate Date:
The Municipality of Anchorage Development. Services Division (DSD) issues Certificates of On -Site Systems Approval (COSA) based only
upon the representations given in paragraph 5 by, an mdependent,professional civil engineer registered in the State of Alaska.. The Municipality
of Anchorage is not responsible for errors or omissions in the professional engineer's work.
7. ATTACHMENTS:
COSA Checklist X Nitrate Advisory
Septic System Advisory Arsenic Advisory
Well Flow Advisory Other
COSA blue sheet_110-10-12.dx _
If more than 1 septic system is on the lot:
COSA Checklist # _of _
Structure served by this system _
Certificate of On -Site Systems Approval Checklist
Legal Description: DEER PARK #1 BLOCK 1, LOT 5 Parcel ID: 051.042.56
A. WELL DATA
Well type PRVr If A, B, or C provide PWSID #
Date completed 6.16.1982 Sanitary seal (Y/N) Y
Total depth 165 ft. Cased to 165 ft.
FROM WELL LOG
Date of test 8-16.82
Static water level 20 ft.
Well production 5 g.p.m.
WATER SAMPLE RESULTS:
Coliform
N/cfr
colonies/100 mL Nitrate
0,/ZS mg/L
Arsenic:
fVA
ug/L Date of sample:
11 -lo -IC
B. SEPTICIHOLDING TANK DATA
Tank Type/Material SEPTIC / STEEL
Tank size 1000 gal. Number of Compartments 2
Foundation cleanout (Y/N) •Y Depression over tank (Y/N) N
Date of pumping 10/15115 Pumper Sanitary
Well Log (Y/N) Y
Wires properly protected (Y/N) Y
Casing height (above ground) 24+ in.
AT INSPECTION
1011512015
110 ft.
Collected by: ARCTERRA
Date installed 10/411982
Cleanouts (Y/N) Y
High water alarm (YIN) N
C. ABSORPTION FIELD DATA
Date installed 10/411982 Soil rating (g.p.d.e or ft'/bdrm) 226 System type DEEP TRENCH
Length 43 ft. Width 3 ft. Gravel below pipe 8 ft.
Total depth 11.7 ft. (Measured 1a-15115) Eff. absorption area 688 ftZ Monitodng tube Y Depression over field N
Date of adequacy test 1011512015 Results (Pass/Fail) PASS For 3 bedrooms
Fluid depth in absorption field before test 56 in. Water added 480 gal. New depth} 64 in.
Elapsed Time: 1440 min. Final fluid depth 54 in. Absorption rate >= 450+ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) N If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at _ in.
Datum
Size in gallons
"Pump off" level at _ in.
Cycles tested
E. SEPARATION DISTANCES
VALL ON LOT TO:
Septic tank/lift station on lot 1001+
Absorption field on lot 1001+
Public sewer main 751+
Sewer /septic service line 251+
Animal containment areas 501+
SEPTIC/HOLDING TANK ON LOT TO:
Manhole/Access (Y/N)
High water alarm level at
Meets alarm & circuit requirements?
On adjacent lots
On adjacent lots
Public sewer manhole%leanout 1004
Holding tank
Manure/animal excrete storage areas 1004
Building foundation 5'+ Property line 51+ Absorption field 5'+
Water main 101+ Water service line 101+ Surface water 1004
Wells on adjacent dots 4004
ABSORPTION FIELD ON LOT TO:
Property line 10'+ Building foundation 10'+ Water main 10'+
Water Service line 10'+ Surface water, 100'+ Driveway, parking/vehicle storage 104
Curtain drain 50'+(N0NE KNOWN) Wells on adjacent lots 1001+
F. COMMENTS
*FCO inside foundation Field operetina in the top half of the effective depth
G. ENGINEER'S CERTIFICATION
I certify that t have determined through field inspections and
review of ifuniclpal records that the above systems are in conformance
with MOA COSA:guidelines in effect on this date.
Engineer's Printed Name KENNETH M. DUFFUS
Date 1011512015.
COSA i;anary shest_,2=6 95.doc
.w OF Al
� sssr K
in.
.ra
Municipality of Anchorage
- 1JCY1'./41�LI7CI R:♦7C.1YWG,3 'VIY1.?IV1► - ,
On Site Water and Wastewater Program
**** VARIANCE/WAIVER REVIEW ****
Lot 6
Lot 5
40,747 s.t.
2.5' PROW
CANT
in
DECK
$,2'x8.3' SHE 6 2�Z
1 STORY
FIRE PIT RESIDENCE Wf
DAYLIGHT BSMT
WELL
1O' UTILITY EASEMENT
Qtr
84.1125
120-64
DEER PARK
DRIVE
15' T&E EASEMENT
PLOT
i•Al
e
r
4
k I
^ r
w �.
�
b
`.WOODENFENCE
Lot 21
15' T&E EASEMENT
PLOT
i•Al
e
r
4
k I
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- -- -
Municipality of Anchorage --
• Development Services Department
Building Safety Division
On -Site Water and Wastewater Program a 5'A E T Y
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
CERTIFICATE OF HEALTH AUTHORITY APPROVAL_
FOR A SINGLE- FAMILY DWELLING
Parcel I.D. os o `'1 Z— Sly hiAF� ; 7iZ
Expiration Date-
1. GENERAL INFORMATION
Complete legal description
Location (site address or directions)
Current Property owner(s) D. Day phone &ISY— 4`/�Z
Mailing address
Lending agency
Mailing address
115l9 r d G'. G� Day phone
Real Estate Agent Day phone
Mailing Address
Unless otherwise requested, HAA will be held by DSD for pickup.
2. NUMBER OF BEDROOMS: ____?
3. TYPE OF WATER SUPPLY: '
TYPE OF WASTEWATER DISPOSAL:
Individual Well
Individual On -site
Individual Water Storage
❑
Individual Holding tank
❑
Community Class Well
❑
Community On -site
❑
Public Water System
❑
Public Sewer
❑
The Municipality of Anchorage Development Services Department (DSD) Issues Certificates of Health Authority
Approval (HAA) based only upon the representations given in paragraph 4 by an independent professional civil
engineer registered in the State of Alaska. Certificates of Health Authority Approval are required for the transfer of
title (except between spouses) for properties served by a single-family on -site wastewater disposal and/or water
supply system. DSD also issues HAAs upon request to homeowners. Certificates of Health Authority Approval are
valid for 90 days from the date of issue for properties served by a private or Class C well and may be reissued with
new water sample results. (Certificates may be reissued for a period of up to one year with valid water. samples.)
Certificates are valid for one year for properties served by Class A or B wells or a public water system. The
Municipality of Anchorage is not responsible for errors or omissions in the professional engineer's work.
_ 4. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my investigation,
based on procedures outlined in the Health Authority Approval Guidelines for this application, shows that the on -
site water supply and/or wastewater disposal system is(are) safe, functional and adequate for the number of
bedrooms and type of structure indicated herein. I further verify that based on the information obtained from the
Municipality of Anchorage files and from my investigation and inspection, the on -site water supply and/or
wastewater disposal system is(are) in compliance with all applicable Municipal and State codes, ordinances,
and regulations in effect at the time of installation.
Name of Firm
Address D �✓�'/r%Jf, �,('/� r�r, .� g��y5'
Engineer's Printed Name
5. DSD SIGNATURE
I� Approved for 3
Disapproved. .
Conditional approval for
Attachments:
HAA Checklist
Septic System Advisory
Well Flow Advisory
In
bedrooms.
Phone 1O;?- 73'- /e," 73
Date
bedrooms, with the following stipulations:
Maintenance Agreements
Supplemental Engineer's Report
Other
By: Original Certificate Date:�nLL
(Rev. 01102)
Municipality of Anchorage
' Development Services Department
Building Safety Division
On -Site Water & Wastewater Program
4700 South Bragaw St.
P.O. Box 196650 Anchorage, AK 99519-6650
www.ci.anchorage.ak.us
(907) 343-7904
Legal Description:
A. WELL DATA
HEALTH AUTHORITY APPROVAL CHECKLIST
lglo"IG% fez, h/ Parcel ID:
Well type �� r c �� If A, B, or C provide PWSID #
Date completed /C 9d Sanitary seal (Y/N)
Total depth %G�5" ft. Cased to ft.
FROM WELL LOG
Date of test 8l/z 1 a.25
Well Log (Y/N)
Wires properly protected (Y/N)
Casing height (above ground) in.
AT INSPECTION
Static water level ft. //O, G ft.
Well production �� g.p.m. D g.p.m.
WATER SAMPLE RESULTS:
Coliform colonies/100 ml. Nitrate 12•1011 mg./I. Other bacteria -1!9- colonies/100 ml.
Arsenic: — mg./I. Date of sample: Collected by:
B. SEPTIC/HOLDING TANK DATA
Tank Type/Material Date installed
Tank size gal. Number of Compartments r Cleanouts (Y/N) _ I/
Foundation cleanout (Y/N) Depression over tank (Y/N) IV High water alarm (Y/N)
Date of pumping Pumper �rv�, �/� �'�% ���-n p /-s
C. ABSORPTION FIELD DATA
Date installed le ,/ YZ Soil rating (g.p.d./ftZ or ft2/bdrm � � System type 7t-el2c l)
Length �� ft. Width 3 ft. Gravel below pipe S ft.
Total depth 149 ft. Eff. absorption area 6,99 ftZ Monitoring tube _ Depression over field /Y
Date of adequacy test a������ Results (Pass/Fail) / For 3 bedrooms
Fluid depth in absorption field before test / in. Water added 3 36 gal. New depth (-;e - YY
Elapsed Time: '513 min. Final fluid depth in. Absorption Absorption rate >_ g.p.d.
Any rejuvenation treatment (past 12 mo.) (Y/N & type) Al If yes, give date
D. LIFT STATION
Date installed
"Pump on" level at
Size in gallons __
in. "Pump off' level at
Cycles tested
E. SEPARATION DISTANCES
SEPARATION DISTANCES FROM WELL ON LOT TO:
Septic tank/lift station on lot iDo rJ
Absorption field on lot i OrJ t �f
Public sewer main
Manhole/Access (Y/N)
level at in.
Meets alarm & circuit requirements?
On adjacent lots
/ D D i 7"7'
On adjacent lots _ /OeJ / i/
Public sewer manhole/cleanout _ Al
Sewer /septic service line �.� r' ��f Holding tank /;
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOT TO:
Building foundation 3 �� Property line /,� f Absorption field
Water main %/ L Water service line o2Jr Surface water
Wells on adjacent lots / -'D f 17"
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOT TO:
Property line ; 3 /,/, Building foundation /D f & Water main /1 /X
Water Service line ? t /71 Surface water %41' Driveway, parking/vehicle storage
%Pone Known
Curtain drain Ta c yl,-Y" Wells on adjacent lots
F. COMMENTS
c �:'.c9 C.� �T'l Gi✓ 4E/,t.-V4r1-- %✓r
ky;, zj
G. ENGINEER'S CERTIFICATION °��° ®••°o"�?R'
6w
1 certify that I have determined through field inspections and ° ��� k^ " `•,
review of Municipal records that the above systems are in ��•' o
conformance with MCA HAA guidelines in effect on this date. ;; ®, • _ �; m�7r
Engineer's Printed Name �s 7 xei'7 /e1, � �'vi••° E 170
!/�+ r/f��.y/ Ifs • ,�sErn^<-
Date J -0 1 �5� •ems®•sear°•h Ven
HAA Fee $ —1 -5L`
Date of Payment
Receipt Number
(Rev. 12/01)
L('. 3 V V r,
Waiver Fee $
Date of Payment
Receipt Number
O MUNICIPALITY RAGE
• �'� DEPARTMENT OF HEALTH
& HUM
H 8 HUMAN SERVICES
Division of Environmental Services
On Site Services Section
P.O. Box 196650 Anchorage, Alaska 99519-665
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. # �:CI-0NZSL
- V
1. GENERAL INFORMATION
rALITY OF ANI-MUAnue
:NTAL SERYICES DIV131ON
o OCT 29 1997
RECEIVED
Complete legal description Lot 5• Block 17 Deer Park Subdivision gT
Location (site address or directions) 99494 Deer Park
Chuaiak AK
Property owner ' ' Charles Moore Day phone
Mailing address C/O Remax of LaalF River 16600 Centerfield nr FaMlp Rivpr. AK
Lending agency
Mailing
Day phone
Agent Virginia Kohfield/ Remax of P' -E- Day phone 694_49nn
Address
Unless otherwise requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS:
3. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
3 N
NOTE: if community well system, provide written confirmation from State ADEC attest-
ing to the legality and status of system.
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site XXX
Holding tank
Community on-site
Public sewer
NOTE: if community wastewater system, provide written confirmation from State ADEC
attesting to the legality and status of system.
72-025 (n.+. 1/91) From MOA 421
5. STATEMENT OF INSPECTION BY ENGINEER
As certified by my seal affixed hereto and as of the validation date shown below, I verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the information obtained from
the Municipality of Anchorage files and from my investigation and inspection, the on-site water
supply and/or wastewater disposal system is in compliance with all Municipal and State codes,
ordinances, and regulations in effect on the date of this inspection.
Name of Firm S & 5 ENGINEERING Phone 6y - A 9 7
—�17C341:29"i
Address Eagle River, Alaska 99577
Engineer's signature
6. DHHrS/ SIGNATURE �1'1�`o��G�G
Approved for L bedrooms.
Disapproved.
Conditional approval for
Additional Comments
Date 10 / a cl /4 7
G OF
ROBERT C. COWAN
'l� i+.��.• CE -8801
;t r.c>`
bedrooms, with the following stipulations:
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given In paragraph 5 above by an Independent
professional engineer registered in the State of Alaska. The DHHS does this as a courtesy to purchasersof homes
and their lendi ng institutions in order to satisfy certain federal and state requirements. Employees of DHHS do not
conduct Inspections or analyze data before a certificate is issued. The Municipality of Anchorage is not
responsible for errors or omissions in the professional engineer's work.
72-075 (R�A/91( e.ck MOA n1
Municipality of Anchorage
DEPARTMENT OF HEALTH & HUMAN SERVICES
Environmental Services Division
825 L Street, Room 502 • Anchorage, Alaska 99501 • (907)
Health Authority Approval Checklist
Legal Description: L. —, '5 9Lc�K ( Dyer P«rk tcl # I Parcel l
A. WELL DATA
MUNI�WALITI' OF AN(
ENVIRON"ENTAL SERVt&N
OCT 2 9 1lul
3RECEIVED
051—oga-56
Well type P2 (yA-T�_ If A, B, or C. attach ADEC letter. ADEC water system number
Log present(Y Date completed
Total depth to Cased to 165, Casing height (above ground)
Sanitary seal (Y N) cyh Wires properly protected i*)_-�eA
FROM WELL LOG
Date of test 6111, 16aL
Static water level ,20
Well production 5 g.p.m.
WATER SAMPLE RESULTS:
Coliform O
AT INSPECTION
ro J.2i/%7
."7 g.p.m.
Nitrate 0./ Other bacteria
0
Date of sample: 10 n - S & S ENGINEERING
of q Collected by: 204
B. SEPTIC/HOLDING TANK DATA Eagle River, Alaska 99677
U�
Date installed -1R Tank size I boU Number of Compartments _0 Cleanouts 1 "N)1 lZ
Foundation cleanout (YUN too Depression (Y& 00 High water alarm (Y/N)
Date of Pumping 0 i 1 Pumper _J '_s
C. ABSORPTION FIELD DATA
f4
Date installed O , z Soil rating (g.p.dJftz or n _226=/bdr_226/z['(System type 'fv,Fw'_N
Length '_ 3 r Width 3 e Gravel thickness below pipe — Total depth Ly e
Elf active absorption area Monitoring Tube present N) 7 Depression over field (Y& efo
Date of adequacy test � Results as ail) QR`,< For TI?P.C.& bedrooms
IT -51
Fluid depth in absorption field before cost (in.); 3 Immediately atter, gal, water added (in.):
11
Fluid depth (ins) Minutes later: Absorption rate =C)� _g.p.d,
Peroxide treatment (past 12 months) (Y/N)t( ^N _ e/erin1 If yes, give date
72-026 (Rev. 3(96)'
D. LIFrSTATION
Date installed f9
Manhole/Access (Y/N)
High water alarm level at* _
Cycles tested
E. SEPARATION DISTANCES
Size in gallons
`Pump on" level at*
`Pump off" level at"
SEPARATION DISTANCES FROM WELL ON LOT TO: _
Septictholding tank on lot ✓ n::>, + On adjacent lots I cx' +
Absorption field on lot Y—f)o•4- On adjacent lots /0
Public sewer main jQ Public sewer manhole/cleanout /, J
Sewer /septic service line 5 + Lift station 1114
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK ON LOTTO:
Orf xwsrrx7wN pEft`2f
Foundation 3r Property line f t Absorption field 5
Water main/service line IPL '� Surface water/drainage Jro14 Wells on adjacent lots ICO
SEPARATION DISTANCE FROM ABSORPTION FIELD ON LOTTO:
Property line 11) 14- Building foundation Ib r ✓ Water main/service line fol +
Surface water I n0 Driveway, parking/vehicle storage area 1 t
Curtain drain A)nnlE Knlow J Wells on adjacent lots I co, +
F. ENGINEER'S CERTIFICATION
I certify that I have determined thru field inspections and review o/ Municipal records t✓�evpy ryti!(gms are
in conformance with MOA
HAA guidelines in effect on this date. rC2�i
Signature
Engineer's Name 0/3 4-Z % C.
// S % 1.903 t C. COWAN i Q
Date 10 (a 9 /R7 j; CE:£801
..
HAA Fee $ %1_J
Date of Payment d
Receipt Number
72-026 (Rev. 3/96)'
Waiver Fee S
Date of Payment
Receipt Number
MUNICIPALITY OF ANCHORAGE
• DEPARTMENT OF HEALTH & HUMAN SERVICES
'Divislon of Environmental Services •''"
On -Site Services Section
P.O. Box 196650Anchorage, Alaska 99519-6650
343-4744
CERTIFICATE OF HEALTH AUTHORITY
APPROVAL FOR A SINGLE FAMILY DWELLING
Parcel I.D. N HAA1#
1. GENERAL INFORMATION +
Complete legal description La r-5 $t.2_
Location (site address or directions) 2- KY 9 L
PropertyownerP3c,4e_o 0,wy AarA",.e_zYK_ Day phone �y6�—yl5lo
Mailing address' O"600- %% /OtoG 0425 Ae77s�o�
Lending agency Day phone
Mailing address
Agent �6,) 1 0_k1r =6-- 2CRc �rmzx Day phone
Address
Unless otherwise, requested, HAA will be held for pickup.
2. NUMBER OF BEDROOMS: 3
3.. TYPE OF WATER SUPPLY:
Individual well
Community well
Public water
NOTE: If community well system, provide written confirmation from State ADEC attest-
• Ing to ttie legality and status of systema •
� "
4. TYPE OF WASTEWATER DISPOSAL:
Individual on-site k
Holding tank'
Community on site
"
Public sewer
"ADEC
NOTE: If community wastewater system, provide written confirrrmation from State
attesting to the legality and status ofsystem.
.. 72-M(Rw.1/91) FW1 MOA021
S. STATEMENT. OF INSPECTION, BY ENGINEER
As certified by.my seal affixed Hereto and as of the validation date shown below, l verify that my
investigation of this Health Authority Approval application shows that the on-site water supply
and/or wastewater disposal system is safe, functional and adequate for the number of bedrooms
and type of structure indicated herein. I further verify that based on the Information obtained from .
the Municipality of Anchorage files and from my investigation and Inspection, the on-site water
supply and/or wastewater disposal system'is7 incompliance with aIi Municipal and State codes;
ordinances, and regulations in effect on the date of this inspection.
David R Dayton P.E. Name of Firm y Phone lo9�i �?7
2021ODonalarbt.
Address_ Chu is Alaska 7 67
Enginee7s signature Date }
. s..... eo%
C t% %%
v�:: ,
v a r• 9L+1 H'�1� r°t
.•• N Ml,• � • i
6. DHHS SIGNATURE
_X1 Approved for bedrooms.
Disapproved.
M
DQV1d P Doyro
NO. =054
Conditional approval for bedrooms, with the following stipulations:
Additional Comments
The Municipality of Anchorage Department of Health and Human Services (DHHS) issues Health Authority
Approval Certificates based only upon the representations given to paragraph 5 above by an independent
professional engineer registered in the State of Alaska. The DHHS does this as, a courtesy to purchasers of homes
and their lending institutions in order to satisfy certain federal and state requirments. Employees ofDHHSdonot
conduct inspections or analyze data before a certificate is Issued.;The Municipality of Anchorage.is not
responsible for errors or omissions in the professional engineer's work. .,
j•, non (Aa• 1/91) 8• k MOA #21 _
Municipality of Anchorage
Department of HealtHand Human Services
HEALTH AUTHORITY APPROVAL CHECKLIST
Legal Description: [O7 -S �Lie- �Eo>t )'/"t4tParcelI.D.
q )
A. Well Data
Well type T;;k4y^'r>g- If A, B, or C, attach ADEC letter. ADEC water system number
Log present (YM) Y Date completed _S/ //- % 4Z Driller a, -,y
Total depth 1 t.r Cased to I rx�S Casing height Z � •'
Sanitary seal (Y/N) Y Wires property protected (YM) V
Date of test
Static water level
Well flow
Pump levelt
FROM WELL LOG
41164-2-
C-0 g.p.m.
7
SEPARATION DISTANCES FROM WELL TO:
Septic/holding tank on lot i 19 ; On adjacent lots J0 0 r
Absorption field on lot I z,0+ ; On adjacent lots I oc T
Public sewer main ^J 14' Public sewer manhole/cleanout
Sewer service line S o +- Petroleum tank A/1,y
WATER SAMPLE RESULTS:
Coliform O Nitrate O, / Other bacteria
Date of sample: /�Z9 Collected by:�
B. SEPTIC/HOLDING TANK DATA
Date installed ro/N_ Tank size I ood Compartments
L
Cleanouts (Y/N) y Foundation cleanout (YM) A-) Depression (YM) A%
High water alar (Y/N) N11- Alarm tested (Y/N) �IA
Date of pumping 9 Lt,41r i Pumper�{� nnM�R-S
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
On adjacent lots I e o *- Foundation 3 t
To property line 0,0- Absorption field 5 Water main/service line r cp '
Surface water/drainage
%00+-
72-026(193)• Fwnt CONTINUED ON BACK PAGE
AT INSPECTION
1
_03 i q�
-
rn
70
t
rn
g.p.m.
?'
N0
'p
J
(<�
rn
4
A
i/
N�
0
z
Septic/holding tank on lot i 19 ; On adjacent lots J0 0 r
Absorption field on lot I z,0+ ; On adjacent lots I oc T
Public sewer main ^J 14' Public sewer manhole/cleanout
Sewer service line S o +- Petroleum tank A/1,y
WATER SAMPLE RESULTS:
Coliform O Nitrate O, / Other bacteria
Date of sample: /�Z9 Collected by:�
B. SEPTIC/HOLDING TANK DATA
Date installed ro/N_ Tank size I ood Compartments
L
Cleanouts (Y/N) y Foundation cleanout (YM) A-) Depression (YM) A%
High water alar (Y/N) N11- Alarm tested (Y/N) �IA
Date of pumping 9 Lt,41r i Pumper�{� nnM�R-S
SEPARATION DISTANCES FROM SEPTIC/HOLDING TANK TO:
Well(s) on lot
On adjacent lots I e o *- Foundation 3 t
To property line 0,0- Absorption field 5 Water main/service line r cp '
Surface water/drainage
%00+-
72-026(193)• Fwnt CONTINUED ON BACK PAGE
C. LIFT STATION
Date installed �✓//�' Manufacturer
Size in gallons Manhole/Access (YM)
Vent (Y/N) 'Pump on' level at 'Pump off" Level at
High water alarm level Cycles tested
Meets MOA electrical codes (Y/N)
SEPARATION DISTANCE FROM LIFT STATION TO:
Well on lot On adjacent lots Surface water
D. ABSORPTION FIELD DATA
Date Installed Soil rating (GPD/Ft) 27 c S`/o'34- System type
Length Width 3 Gravel thickness gy Total depth / z
Total absorption area oB8 Cleanout present (Y/N) Y Depression over field (YM) N
Date of adequacy test 313 r 9' < Results (pass/fail) P+n� for 3- Bedrooms
Water level in absorption field before test i42" After test '/i " /2-A".r
Peroxide treatment (past 12 months) (Y/N) Al If yes, give date
SEPARATION DISTANCE FROM ABSORPTION FIELD TO:
Well on lot I Z_04 --On adjacent lots 1 O o +- Property line 3
To building foundation I o' To existing or abandoned system on lot
On adjacent lots oa 4 Cutbank _�/a Water main/service line Z Sf
Surface water I e o +- Driveway, parking/vehicle storage area 15�
Curtain drain o^ic r JII`v vJ
E. ENGINEER'S CERTIFICATION
I certify that I have checked, verified, or conformed to all MOA and HAA guidelines in e/%4(cimRi�Z'Jra p{this inspection.
David R. Dayton P.E.
vir '.'1•Sir aft.
20210 Donalar St.
Signature
Chu iak Alaska 9567
.
En g ineer's Name
M� M..MY :...^.•
"Da u R• ca�^� .W 1
// /
� d • hd. "_iii :"�°
�Q�9F�
Date
�T�195�
•••,......• '�':•e
HAA Fee $ O'CO -WD
Date of Payment _ 6 -?
Receipt Number v2S y 77
72-026 (yas)* Back
Waiver Fee $
Date of Payment
Receipt Number
DA
a Y(.•f•.jZWdE M Chugiak,99567
i iis•. •..iti,,.
20210 ••
April 1, 1994
Adequacy Test
__ Legal Description: Lot 5, Blk 1, Deer Park Estates Addn H1
Date of Test: March 31, 1994
Septic Tank: 1000 gallon, 2 compartment, steel tank (DIM Records)
Absorption System: 43' long x 3' wide x 8' effective depth trench (DHHS Records)
Soils Rating: 226 sq ft per bedroom
Requirements: 3 BR - 450 gallons per day
(DHHS Records)
Test:
Water was pumped into the trench while measuring volume arra water level
rise at timed intervals. After pumping was stopped, the water level drop
was measured at timed intervals.
The results were plotted on a graph of time and gallons absorbed and
extrapolated to 24 hrs.
Results:
The absorption trench is currently functioning adequately for a 3 BR home.
OF 41-
W t.X
Dar:d R. Doylro
No. 2101 r
;r'ROFfS'+ �•'':-rye
D. R. DAYTON,-P.E., R.L.S.
4dG'o9&cBa&A 2B Chugiak, Alaska 99567 (907) EBae
20210 Donalar 696-2417
April 1, 1994
Well Flow Test
Legal Description: Lot 51 Blk 1, Deer Park,Estates Adan H1
Date of Test: March 31, 1994
Well Depth: 165'
Static Water Level: 109'
Requirements: 3 BR - 450 gallons per day
Test: I
The well was tested with the existing pump through a hose bib ahead
of the pressure tank.
The volume and drawdown were measured at timed intervals. Recovery was
measured after pumping was stopped.
Results:
The well produced 1945 gallons in 240 minutes at an average flow rate
of8.1 gallons per minute.
The maximum drawdown was 6' which fully recovered within 6 minutes after
the pump was shut off.
The well is currently producing adequately for a 3 BR home.
s � �� f Ei ti�� �• t
.... ..•...............
`i4a cIt
c David R Day al 1
i� % 180. 2C05 E �•.% .
• �BEAIL C cy.�rY��ss
MUNICIPALITY OF ANCHORAGE L
DEPARTMENT OF HEALTH 8 HUMAN SERVICES j
DIVISION OF ENVIRONMENTAL SERVICES
CERTIFICATE OF INSPECTION FOR HEALTH AUTHORITY APPROVAL
OF ON-SITE SEWER AND WATER FACILITY
264-4744
Application Date
1. GENERAL INFORMATION (MUST BE COMPLETED PRIOR TO SUBMITTAL)
(a) Legal Description (include lot, block, subdivision, section, township, ranggJ
5 YJL .
Location (address or directions)
(b) Property Owner ks 14 F L Telephone: Home Business
Mailing Address 2 75 ��S' p• -1L -=-1g501
(c) Lending InstitutionTelephone
Mailing Address
(d) Real Estate Company and Agent �/x�c� �>J t-: rfY-- l—�• —� �JD4- 1'�iy-r �rJ �fL.
Address GSC+ r��L- P• rte.'��c '1 '1 11419 I� , �. X195 -I 7
Telephone lo"ll Ll' SSE -b
(e) ital the HAA to the following address: or: Check here$, if hold for pick up.
List contact person and day phone number below.
5 8 S ENGIN-cEBINC
7034-Ee21e-Rirerta0p-Ro "ai-"4
Eagle 12)ver, Alaska 99577
2. TYPE OF RESIDENCE
Single -Family 13 -
Number of Bedrooms
3. WATER SUPPLY
Individual Well V- Community ❑ Public ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
4. SEWAGE DISPOSAL
Onsite rr- Public ❑ Community ❑ Holding Tank ❑
Note: If community well system, must have written confirmation from the State Department of Environmental Conservation
attesting to the legality and status.
Pagel of 2 77.025 IAP. B-061 Fmm
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-miom s,iaaul6ua
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elep ozAlsue jo suolloadsu! jonpuoo Iou op SHHO jo saaAoldw3 •sluawailnbai aleis pue Ieiapaj ulellao Alslles of japio
u! suo!lnl!lsul 6ulpual nayl pue sawoy 10 siasegoind of Asellnoa a se s!yl saop SH H o ay1'e>fsely Io lei a41 u! pajals!6ai
iaaul6ua Ieuolssaloid juapuadapul ue Ag anoge 5 ydei6ejed ul u9nl6 suolleivasaidai ayj uodn Aluo paseq sainiplrao
Ienaddy Aluo4lnV ylleaH sanss! (SHHo) saolniaS uewnH pue y11eaH jo juawlieda0 o6ejoyouV jo Aj!led!olunyy ay1
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d............
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Aq swowpaq ---g— lo} panaddy
1VAOHddV SHHO '9
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ssajppv
W -ON Peojj dool xnljl a16e3 KOLL
9
auoydalalON11133NION33'Es .,!_I jo eweN
'uog3adsui slyl to alep ayj
uo loolia ui suolleln6ai pue •saoueu!pio'sapoo olelS pue ledlolunW Ile yl!m eouelldwoo ui si wolsAs lesodslp jaiemalsem
jo/pue Alddns ialem al!s-uo eyl 'uoljoadsuo pue uolle6psanul Aw woil pue sal!1 a6ejo4ouV jo AUledlolunyy ayl waj
paulelgo uo!lewjolui ayi uo paseq Ieyl Ajuan jayUnj I -umay paieolput ajnlonlls jo adAl pue swoojpaq 10 iagwnu ayj jo;
alenbape pue leuo!launl'ales sl waisAs lesodslp ialemaisem io/pue Alddns ialem alis-uo ayj )Lql SmbljS IenaddV Aluoyjn V
yjleaH s"A 10 uo1je6llsanul Aw leyi Aluan I'molaq umoys alep uoyepgen ayi to se pue ojajay paxyle leas Aw Aq pay!Uao sV
NOI.LVWHOdNI (INV VIVO'HOUV3S 311d'S1S31'SNOIl33dSNl ONIOIAOHd YOU ONI1133NION3 'S
A. WELL DATA
MUNICIPALITY OF ANCHORAGE (MOA)
MUNICIPALITY OF fMEWL-t"LITHORITY APPROVAL (HAA)
ENVIRONMENTAL SERVICES bilVdkLIST - FEBRUARY 1984
264-4744
{',i 51988
RECEIVED
Legal Description: S i
22azr_?== tfs-y-1 1
a
Well Classification .( tJt2J 10, ).611, If A. B. C, D.E.C. Approved (Y/N) A,
Well Log Present (?N) Date Completed 13 — llo f132 Yield B,Z C PM
r r
Total Depth 11-06 Cased to 1 l05 Depth of Grouting
Static Water Level 10-1 Pump Set At �•�'
q
Casing Height Above Ground IZ Sanitary Seal on Casing(tVN)
Electrical Wiring in Conduit&N)
Separation Distances from Well:
Depression Around Wellhead (Y/O
To Septic/Hetding-Tank on Lot I oor '1- ; On Adjoining Lots
To Nearest Edge of Absorption Field on Lot t nth ; On Adjoining Lots I t
To Nearest Public Sewer Line � To Nearest Public Sewer 1
Cleanout/Manhole <' To Nearest Sewer Service Line on Lot 7-S 4 -
Water Sample Collected by �• lJ �+`�� l i t ; Date
Water Sample Test Results �7hTl�iF7�irb¢� / — ��ii'i• N ria. .4_
Comments
B. SEPTIC/HOt0fNG TANK DATA
Date Installed -$ZSize 1 9Z]z2L-2 No. of Compartments
'2—
Standpipes
Standpipes LPN) Air -tight Caps MN) Foundation Cleanout (YO
Depression over Tank (Y/JT Date Last Pumped 17- 'Zq f3
Pumping/Maintenance Contract on File (Y/N) A ; for
Holding Tank High -Water Alarm (Y/N) �Temporary Holding Tank Permit (Y/N) a A
Separation Distances from Septic/Hstdmg Tank: ,
To Water -Supply Well loo I To Building Foundation
To Property Line -- To Disposal Field
t
To Water Main/Service Line ) N7 To Stream, Pond, Lake, or Major Drainage
Course t F'
Comments ��-S G-1y�5 Pont_ PJ.�tPI�GI. SC 6'1 r1L2
Page 1 012
72-M Qinv 8 1161 Front
C. ABSORPTION FIELD DATA
Soils Rating in Absorption Strata 22'b Ve Type of System Design
Date Installed o - A- -Length of Field 4'7
r �
Width of Field Depth of Field (Z
Gravel Bed Thickness
Square Feet of Absorption Area ko80_015 Standpipes PresentQN)
Depression over Field
Results of Last Adequacy Test
Date of Last Adequacy Test
Separation Distance from Absorption Field:
To Water -Supply Well I o01{- To Property Line 23r
To Building Foundation To Existing or Abandoned System on
Lot On Adjoining Lots 1+
To Water Main/Service Line I o 1� To Cutbank (if present) a
To Stream/Pond/Lake/or Major Drainage Course � t=>o Ih
To Driveway, Parking Area, or Vehicle Storage Area `50 t�
Comments Yf \46 �T V_ ->,J I To2i r
'Pv--t-riA>✓ D��JQ c)!
D. LIFT STATION
'Bete'Installed
Size in Gallons
"Pump On" Level at
High Water Alarm Level at _
Tested for
Electrical Codes (Y/N)
Comments
Dimensions
Manhole/Access (Y/N)
"Pump Off" Level at
•• Check Permitted Bedroom Rating Against HAA Request ••
Vent(Y/N)
Cycles during Adequacy Test. Meets MOA
I certify that I have checked, verified, or conformed to all YOA #nd HAA guidelines in effect on the date of this inspection.
SignSd+ENGNEERING Date V �� • ?:
17034 EaIge Rlver LoopRoad No. 204o�y
Coryap R}�r�laska-99577 MOA No. 'oo_? .. r
Receipt No. a O O / - On n cI
Date of Payment �- - �Ez N c' yam~ t ,
p o �y _tet • i .. w,,.•+..
Amount: $ / 7 O i •er's Se d
�6 �� ;,b.ct A. syr�i •; Y.0 ��
�, :: (•F. lis?.6 � .�s
Page 2 of 2
72.0?6 IRPv M1 Pacts
r
CHEMICAL & GEOLOGICAL LABORATORIES OF ALASKA, INC.
5633 B STREET ANCHORAGE, ALASKA 99518 TELEPHONE (907) 5622343
FEDERAL TAX :D k 92-0040440
Client POI
: VERBAL Req #:
Work Order No. : 4520
Client Smpl ID: LT 5 BLI 1 DEER PARI# 12-28-87
Client Account : SHStNGP
Date Report Printed: DEC 3187 9 13:16
Sample Rec'd
: DEC 29 87
Released By : 2 Wf--
Ordered By
: S 3 S
Reports Address 12
Send
Reports To:
S 8 S ENGINEERING
R SCHAEEER
17034 EAGLE RIVER LOOP RD., #204
. .
EAGLE RIVER, Al. 99577
Special HOLD FOR PICT UP
Instruct:
Chemlab Ref #: 8718 Lab Smpl to: 1 Matrix: Water
Allowable
Parameter Tested Result/Units Method Limits
-----------------------------------------------------------------------------------------------------
HITRATE-N 0.13 K/I 10
Sample ROUTINE SAMPLE
Remarks: ANALYSIS COMPLETED: 12-31-87 / G/
LABORATORY SUPERVISOR: STEPBEli C. EDE
I Tests Performed 1: See Special Instructions Above
ND= None Detected ii See Sample Resarks Above
NAz Not Analyzed LT -Less Than, CT -Greater Than
Y^,
'
RECEIVED
INSPECTION APPOINTMENTS
TIME
TIME CA.S ptu OptDATE
6. TYPE OF RESIDENCE
-n_
JIDNSPECTOR
DATE
21 SINGLE FAMILY
❑ Two ❑ Five
❑ MULTIPLE FAMILY
C2� Three ❑ Six
INSPECTOR
INSPECT
n
' ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
n
MUNICIPALITY OF ANCHORAGE
s.
.TENVIR
\ DEPARTMENT OF HEALTH&ENVIRONMENTAL PROTECTION
825 L Street • Anchorage, Alaska 99501
• 1
. . J ^ 1 1 7
1 I�V
ENVIRONMENTAL SANITATION DIVISION
Telephone 264-4720
RECEIVED
REQUEST FOR APPROVAL OF INDIVIDUAL WATER AND SEWER FACILITIES
DI RECTIONS: Complete all parts on page 1. Incomplete requests will not be processed. Please allow ten (10) days for processing. X
1. PROPERTYOWNER
PHONEp
Cri7 w.+ r
BJ�j 93
MAILING ADDRESS
J o/Y / /- /^-�.�
PROPERTY RESIDENT (11 different from abow;l
PHONE n/ /
G
/c rso <�
SES O a
, <. r
2. BUYER
PHONE
/¢-
LS/��G � OH U �✓ �✓SO-�
- Dti /Ub O
MAILING ADDRESS
��++ h
p
3. LENDING INSTITUTION
PHONE
,t,o
MAILING ADDRESS
0. REALTOR/AGENT
/PHONE
MAILING ADDRESS ,
20 �/J
5. LEGAL DESCRIPTION
!�
STREET LOCATION
6. TYPE OF RESIDENCE
NUMBER OF,BEDHOOMS
❑ One ❑ Four ❑ Other
21 SINGLE FAMILY
❑ Two ❑ Five
❑ MULTIPLE FAMILY
C2� Three ❑ Six
7. WATER SUPPLY
CEr INDIVIDUAL'
' ATTACH WELL LOG. A well log is required for all wells drilled
❑ COMMUNITY
since June 1975. For wells drilled prior to that date, give well
❑ PUBLIC UTILITY
depth (attach log if available.)
B. SEWAGE DISPOSAL SYSTEM
0 INDIVIDUAL/ON-SITE"
9.2— YEAR ON-SITE SYSTEM WAS INSTALLED.
❑ PUBLICUTILITY
NOTE: THE INSPECTION FEE MUST ACCOMPANY EACH REQUEST BEFORE PROCESSING CAN BE INITIATEQ
72010(R-- 6/79) p� /
.. THIS SIDE FOR OFFICIAL USE ONLY
1. TYPE OF RESIDENCE
❑ SINGLE FAMILY
❑ MULTIPLE FAMILY
NUMBER OF BEDROOMS
❑ ONE ❑ THREE ❑ FIVE ❑ OTHER
❑ TWO ❑ FOUR ❑ SIX
2. WATER SUPPLY
❑ INDIVIDUAL
❑ COMMUNITY
❑ PUBLICUTILITY
Connection Verified
PERMITNUMBER
DEPTH OF WELL
DATE DRILLED
LOG RECEIVED
3. SEWAGE DISPOSAL SYSTEM
❑INDIVIDUAL/ON-SITE
❑PUBLIC UTILITY
Connection Verified
PERMIT NUMBER
DATEINSTALLED
0 _ 8 Z
INSTALLER
❑SepticTankor ❑Holding Tank
Size:P71 0y If Tank is homemade
give dimensions:
SOILS RATING
TYPE OF TANK
MANUFACTURER
TOTAL ABSORPTION AREA
MATERIAL
4. DISTANCES
WELL TO:
Septic/Hold.ng Tank
Absorption Area
Sewer Line
Nearest Lot Line
Absorption Area to nearest Lot Line
5. COMMENTS
Gi --APPROVED FOR BEDROOMS
❑ CONDITIONAL APPROVAL (letter must accompany certificate)
❑ DISAPPROVED
DATE 1 e�
BY �r�/
i.�lA�"
72010 (Rev. 6/79)